Cancer affects the kidney in many ways.
Education of the cancer specialists is important. Lately I have felt that the "kidney" has been ignored in many ways in the oncology world.
Recently, a review was published in NEJM
on cancer survivorship and how long patients with cancer are living and the non
cancer related complications. There was no mention of CKD and kidney related
complications. Several studies have shown that CKD is an independent factor for
mortality and cancer related mortality in cancer patients. Few of us wrote a letter to the editor
raising this concern. The response from the author was that “ CKD has a high
mortality and not specific to cancer survivors”. This is an important message
for our heme/onc colleagues to understand that CKD can add to the risk for
cancer survivors. Having early nephrology care and co-managing and preparing
for CKD related complications is important.
Another
important ignored concept in Oncology is lack of studies that include patients
with low GFR. In a recent analysis published in JAMA, Eighty-five percent of
recent trials of therapies for the 5 most common malignancies (published in
selected high–impact factor journals) excluded patients with CKD. This
proportion exceeds that observed in cardiovascular trials published from 1985
through 2005. This
finding is concerning because it was estimated that 32% of deaths among
patients with CKD in 2005-2009 were attributable to malignancy. As a result of
trial under-representation, patients with CKD may not be considered for cancer
therapies that have potential to improve morbidity and mortality.
Also,
most trials used serum creatinine or CrCl thresholds to exclude patients,
despite data demonstrating that these are sub-optimal measures of kidney
function in cancer patients. Given the availability of more
accurate and validated methods for estimating kidney function, the oncology drugs
trials cannot just rely on creatinine measurements.
Finally,
two recent reviews published in NEJM and JAMA on immunotherapy related
toxicities failed to mention renal toxicities. Liver and kidney are two organs that are responsible for most drug
metabolisms. Ignoring those side effects is probably not a good idea. Space limitations and % incidence of renal incidence being low were cited reasons for
not including renal toxicities.
As
a renal community, it is important that we respond back and make sure the voice
of the nephrologists is heard as more and more novel agents are in the market
to treat cancer.
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